Gastric tuberculosis. Endoscopic cytology as a diagnostic tool

OBJECTIVE: To highlight the utility of endoscopic brush smears in the diagnosis of gastric tuberculosis in clinically unsuspected cases. STUDY DESIGN: A retrospective analysis of endoscopic brush smears from 210 patients with gastric symptoms. In seven of these patients (3.3%) the possibility of gastric tuberculosis was suggested in Giemsa-stained smears. Biopsy was available in all cases. Ziehl-Neelsen stain to demonstrate tubercle bacilli was used in brush smears and biopsies in seven and three cases, respectively. RESULTS: Endoscopically the sites involved were antrum (two), pylorus (two), pylorus and duodenum (three). One patient had an ulcerative lesion, and six had growths. Granulomas and/or epithelioid cells were seen in brush smears in all cases. Tubercle bacilli could be demonstrated in cytologic smears in four cases. Endoscopic biopsy showed granulomas in five cases and non-specific gastritis in two. Tubercle bacilli could not be demonstrated in any of the biopsy sections. On further clinicoradiologic investigation, two patients were found to be follow-up cases of pulmonary and nodal tuberculosis. Enzyme-linked immunosorbent assay for HIV, done in three cases, was negative. A final diagnosis of primary gastric tuberculosis in five patients and secondary in two was considered. Six patients responded to antituberculosis treatment and showed healing of the lesions on repeat endoscopy after six months of therapy, while one was a recent case with four weeks' follow-up. CONCLUSION: Endoscopic brush cytology is a reliable modality for the diagnosis of gastric tuberculosis.     

Gene expression profile in human late radiation enteritis obtained by high-density cDNA array hybridization

Late radiation enteritis is a sequela of radiation therapy to the abdomen. The pathogenic process is poorly understood at the molecular level. cDNA array analysis was used to provide new insights into the pathogenesis of this disorder. Gene profiles of six samples of fibrotic bowel tissue from patients with radiation enteritis and six healthy bowel tissue samples from patients without radiation enteritis were compared using membrane-based arrays containing 1314 cDNAs. Results were confirmed with real-time RT-PCR and Western blot analysis. Array analysis identified many differentially expressed genes involved in fibrosis, stress response, inflammation, cell adhesion, intracellular and nuclear signaling, and metabolic pathways. Increased expression of genes coding for proteins involved in the composition and remodeling of the extracellular matrix, along with altered expression of genes involved in cell- to-cell and cell-to-matrix interactions, were observed mainly in radiation enteritis samples. Stress, inflammatory responses, and antioxidant metabolism were altered in radiation enteritis as were genes coding for recruitment of lymphocytes and macrophages. The Rho/HSP27 (HSPB1)/zyxin pathway, involved in tissue contraction and myofibroblast transdifferentiation, was also altered in radiation enteritis, suggesting that this pathway could be related to the fibrogenic process. Our results provide a global and integrated view of the alteration of gene expression associated with radiation enteritis. They suggest that radiation enteritis is a dynamic process involving constant remodeling of each structural component of the intestinal tissue, i.e. the mucosa, the mesenchyme, and blood vessels. Functional studies will be necessary to validate the present results.     

Bronchiolar Carcinoma: A Report of Six Cases

Bronchiolar carcinoma is a malignant tumour which apparently arises in a terminal bronchiole from which it spreads either by bronchial embolization or by lymphogenous and/or hematogenous dissemination. It is not a common neoplasm.Histologically, the tumour bears a striking resemblance to the disease of sheep, jagziekte, which is of virus etiology. A very common finding in reported cases is preexisting pulmonary fibrosis. At the Nova Scotia Sanatorium, Kentville, 80 cases of primary lung cancer have been encountered within the past 25 years. Six of these were bronchiolar carcinomas. Five patients had co-existing chronic pulmonary disease, bronchiectasis in one and tuberculosis in four. One patient died of a rapidly progressive bilateral lesion and five were explored. Lobectomy was done in all five, but in one for palliation only. Three patients are alive and well three, six and 14 years, respectively, after their operations.     

CURRENT VIEWS ON GENITOURINARY TUBERCULOSIS

Tubercle bacilli are spread by the blood stream to the kidney in miliary fashion from the primary pulmonary lesion. Activation, followed by arrest, may delay development of the disease in the kidney for many years or “healing” may occur. Renal ulcerative lesions are the most frequent source of infection of other genitourinary organs.In pyelograms there is no particular characteristic of lesions of tuberculosis. Cellular elements in the urine of a patient with tuberculosis of other organs should lead to urine culture and guinea pig inoculation for mycobacterium tuberculosis.Treatment with streptomycin, isonicotinic acid and/or para-aminosalicylic acid should be started as soon as genitourinary tuberculosis is proved. Patients with advanced lesions usually receive great benefit from these medications; even though organisms may not be eliminated they are definitely diminished in activity. Excision of diseased organs or tissue may be necessary in a few cases.     

Surveillance of Elderly Hospital Patients for Pulmonary Tuberculosis

A restrospective study of pulmonary tuberculosis in a general hospital showed that the diagnosis had been frequently overlooked in the middleaged or elderly because the patient also suffered from a more acute condition which preoccupied the attention of the doctor. The commonest error was to discount chest x-ray abnormalities by omitting sputum culture or serial radiography.Surveillance was carried out on all patients aged 60 or over admitted to a large general hospital whose routine chest radiograph showed signs of possible pulmonary tuberculosis whether apparently active or inactive. Three sputum samples from each patient were examined for Mycobacterium tuberculosis without reference to the clinical presentation. In a nine-month period six out of 81 patients proved to have active pulmonary tuberculosis (7·4%). It is suggested that this may be a useful method of screening the elderly hospital population for pulmonary tuberculosis.     

Surgical Management of Regional Enteritis

The present-day concepts concerning the surgical management of regional enteritis are reviewed and the multitude of problems that may arise in surgical treatment are discussed. The primary treatment of regional enteritis remains medical. Surgical intervention is necessary only for the complications of intractability, obstruction, fistula, abscess formation, anal and rectal complications, massive hemorrhage and perforation. To ensure the best possible results, medical treatment should continue after surgery. A perfect operation for this disease does not exist. Operations for regional enteritis can now be performed with a mortality rate of less than 2%, and although the recurrence rate following surgery averages approximately 30%, the disease is well controlled in the majority of patients with medical and/or surgical treatment.     

L'Anastomose cavo-pulmonaire dans les malformations tricuspidiennes: Evolution de 10 cas opérés

Certain congenital malformations affecting the rightsided cavities of the heart and accompanied by a diminished pulmonary blood flow can be improved by an end-to-side anastomosis between the right pulmonary artery and the superior vena cava. Nine out of the 10 patients who underwent the operation survived. The results have been very impressive in six patients with tricuspid atresia who were critically ill. The anoxemic episodes ceased completely and cyanosis has disappeared. Three cases of Ebstein''s anomaly have also been improved. This clinical study has given us the opportunity to review the physiological consequences of the anastomosis, its complications and its surgical indications. We believe that this type of shunt is especially indicated in cases of tricuspid atresia, in which only a palliative form of surgery can be performed.     

Rubella Syndrome—Cardiovascular Manifestations and Surgical Therapy in Infants

Of nine patients under five months of age with cardiovascular manifestations of the rubella syndrome, six had patent ductus arteriosus. Three of these six also had pulmonary artery stenosis. One infant had bilateral isolated pulmonary artery stenosis. The significant clinical findings leading to the diagnosis of pulmonary artery stenosis were axillary murmurs in the presence of right ventricular hypertrophy. Demonstration of a gradient across the stenosis at the time of catheterization, together with cineangiography, established the diagnosis. In two cases ventricular septal defect was the only cardiac anomaly.Six babies under five months of age had interruption of a patent ductus arteriosus because of uncontrollable congestive heart failure or failure to thrive. Although growth failure was not necessarily due to heart disease, all were developing satisfactorily following operation.Diagnosis and therapy of the cardiac complications of the rubella syndrome is possible in the first few months of life. Early recognition of cardiac defects in the young infant with the rubella syndrome permits aggressive medical management and in selected instances surgical therapy.     

The Ulcerating Tuberculous Hilar Gland

In primary infection tuberculosis, the infected hilar gland(s) may cause involvement of peripheral lung tissue not only by pressure but also by rupture and discharge of caseous material into a bronchus. Atelectasis or lung infection or both may result and bronchiectasis may ensue.Early bronchoscopy is required when this form of tuberculosis fails to subside promptly under treatment.Bronchography is indicated to detect residual bronchiectasis which should be removed surgically.Three of six proved cases of Group A tuberculous tracheobronchitis caused by an ulcerating hilar gland required pulmonary resection for removal of residual bronchiectasis; two of these were complicated by atelectasis. All six patients are alive and well.     

A study of small bowel tumors; with special emphasis on clinical aspects

Ninety-eight patients with 100 different tumors of the small bowel were studied. There were more malignant than benign tumors. Adenocarcinoma was the commonest lesion and the ileum the most frequent anatomical site of all tumors. Except for carcinoid tumors, the lesions were observed more often in male than in female patients. The average age of patients in this series was higher than that reported in most other series. Loss of weight, and abdominal pain were the most constant symptoms. Clinical syndromes of anemia and bleeding, small bowel obstruction, biliary obstruction, perforation with peritonitis, abdominal tumor, melanosis with small bowel polyposis, and cutaneous von Recklinghausen's disease with small bowel neurofibromatosis were encountered either alone or in combination. In the group operated upon, a resection of the involved segment with end-to-end anastomosis was done when feasible. None of the patients operated upon before 1946 lived as much as five years after operation. The most common causes of death were extension of the primary tumor and metastasis, peritonitis due to perforation, associated bronchopneumonia, and hemorrhage.     

Specific antibodies and mycobacterial antigens in patient sera with pulmonary tuberculous and nontuberculous diseases. Note II

"Two-assay" tests (TAT), immunoenzymatic determination of both specific antibodies and mycobacterial antigens in sera of tuberculous and non-tuberculous subjects, was undertaken in our territorial conditions, where BCG vaccination is systematically applied and the prevalence of tuberculous infection is relatively high. The sensitivity of the method, calculated on 42 patients with active pulmonary tuberculosis and on 39 patients with post-tuberculosis syndromes is high, i.e. 0.952. The specificity of the method separately calculated for 44 young subjects (under 21 years old), for 78 healthy adults and for 201 lung diseased patients, bacteriologically not ascertained as tuberculosis at the moment of sera prelevation, varied between 0.830 and 0.489. "TAT", performed with crude immunologic reagents, produces false-positive reactions in early BCG vaccinated subjects. Method specificity low values in pulmonary non-tuberculous patients group may be partially explained by the difficulty in establishing the real relationships, in time, between host and mycobacteria, by the bacteriological method imperfections or sample prelevating methods. Our results certainly underestimate the diagnosis value of "TAT".     

Microdiverticula and submucosal epithelial elements in ulcerative and granulomatous diseases of the ileum and colon

A case of granulomatous ileocolitis which also showed features of ulcerative colitis, and in which lesions were believed to be due to inflammation of previously undescribed structures, microdiverticula, was reported previously. Subsequently, sections of the segments of bowel received from 17 cases of regional enteritis and 16 cases of ulcerative colitis were re-examined for the presence of similar microdiverticula and submucosal epithelial elements. The same structures were present in five cases of regional enteritis and in 14 of ulcerative colitis. A granulomatous type of inflammatory response was found in the bowel and lymph nodes in 14 of the 17 cases of regional enteritis, and in none of the cases labelled ulcerative colitis. In spite of this, difficulty was experienced in placing some cases in one or other diagnostic category. This re-emphasizes the possibility that the two conditions may not be etiologically discrete, and that both may be, in fact, related to the presence of microdiverticula. In addition, it may be that colitis cystica profunda is a result of microdiverticulosis in which the submucosal glandular structures attain unusually large proportions.     

A STUDY OF SMALL BOWEL TUMORS—With Special Emphasis on Clinical Aspects

Ninety-eight patients with 100 different tumors of the small bowel were studied. There were more malignant than benign tumors. Adenocarcinoma was the commonest lesion and the ileum the most frequent anatomical site of all tumors. Except for carcinoid tumors, the lesions were observed more often in male than in female patients. The average age of patients in this series was higher than that reported in most other series. Loss of weight, and abdominal pain were the most constant symptoms. Clinical syndromes of anemia and bleeding, small bowel obstruction, biliary obstruction, perforation with peritonitis, abdominal tumor, melanosis with small bowel polyposis, and cutaneous von Recklinghausen''s disease with small bowel neurofibromatosis were encountered either alone or in combination.In the group operated upon, a resection of the involved segment with end-to-end anastomosis was done when feasible. None of the patients operated upon before 1946 lived as much as five years after operation. The most common causes of death were extension of the primary tumor and metastasis, peritonitis due to perforation, associated bronchopneumonia, and hemorrhage.     

Successful use of an inhalational phytochemical to treat pulmonary tuberculosis: a case report.

Multi-drug resistant strains of tuberculosis pose a serious threat in many third- and first-world countries. The aim of this case report is to describe a potential new method for treating those with primary pulmonary tuberculosis using phytochemicals via inhalation. We report the first case of using inhaled phytochemicals in treating primary pulmonary tuberculosis. A 28-year-old female presented with symptoms suggestive of primary pulmonary tuberculosis, and she was found to be positive via chest X-ray and sputum culture. She subsequently underwent treatment with conventional DOTS treatment. Ten days post-inhalation of the phytochemical, the patient is tuberculosis negative (via sputum culture), with no clinical symptoms. This may be a potential new method and type of treatment for pulmonary tuberculosis.     

Esophageal tuberculosis. Endoscopic cytology as a diagnostic tool

OBJECTIVE: To study the utility of endoscopic cytology in the diagnosis of esophageal tuberculosis in clinically unsuspected cases. STUDY DESIGN: During a period of four years, endoscopic cytology of esophageal lesions was performed on 228 patients. In eight (3.5%) the cytologic diagnosis of esophageal tuberculosis was suggested on smears. Upon endoscopic examination, the sites of involvement were mid esophagus (five cases), upper esophagus (two cases) and lower esophagus (one case). Linear ulcer was seen in six cases; growth and narrowing of the lumen were seen in one case each. Endoscopic brush smears in seven cases and fine needle aspiration cytology smear in one case were collected. Air-dried smears stained by Giemsa stain were reviewed for detailed cytologic assessment. RESULTS: Smears showed well-defined granulomas with necrosis in five cases and granulomas without necrosis in three. Cytologic evidence of concurrent poorly differentiated squamous cell carcinoma was observed in one case. Tubercle bacilli were demonstrated in five cases. Endoscopic biopsy showed granulomas in three cases and tubercle bacilli in one case. In six cases there was no clinical or radiologic evidence of tuberculosis at other sites, thereby suggesting the possibility of primary esophageal tuberculosis. The remaining two cases had a past history of tuberculosis; one presented with cervical lymphadenopathy and one mediastinal lymphadenopathy. All patients received antitubercular treatment, and the patient with concurrent malignancy also received radiotherapy. All but one of the patients who succumbed to aspiration pneumonia responded to treatment. CONCLUSION: Endoscopic cytology is a useful modality in the diagnosis of esophageal tuberculosis in clinically unsuspected cases.     

Tuberculosis in HIV-infected patients in Croatia between 1986 and 2005

A retrospective medical chart review was performed on 65 HIV-infected patients with tuberculosis hospitalized between 1986 and 2006 at the University Hospital for Infectious Diseases "Dr. Fran Mihaljevi?", Zagreb. Thirty two patients presented with pulmonary involvement, 13 with extrapulmonary, and 20 patients had disseminated tuberculosis. Forty five patients had an abnormal chest X-ray. Mycobacterium tuberculosis was identified in 35 (53.9%) patients. Ten (15.3%) of 65 patients had already been receiving antiviral therapy, while another 31 (47.7%) initiated antiviral therapy after antituberculosis therapy. Tuberculosis-associated immune reconstitution inflammatory syndrome was observed in 11/27 (40.7%) patients. Forty one patient received the standard six month course of antituberculous therapy, while in 12 patients the therapy was prolonged. Twenty one patient (32%) experienced an adverse event to antituberculosis drugs. Twelve patients died (18.5%). After the introduction of highly active antiviral therapy (HAART) the mortality decreased. The incidence of tuberculosis in HIV-infected patients in Croatia is increasing, and tuberculosis is still an important opportunistic infection in our HIV-infected patients.     

Significance of venous anastomosis in fingertip replantation

Adequate venous outflow is the most important factor for successful fingertip replantation. The authors have attempted venous anastomosis in all cases of fingertip replantation to overcome postoperative congestion. In this article, the significance of venous repair for fingertip replantation is described from the authors' results of 64 complete fingertip amputations in 55 consecutive patients, which were replanted from January of 1996 to June of 2001. The overall survival rate was 86 percent. Of the 44 replantations in zone I, 37 survived, and the success rate was 84 percent. Of the 20 replantations in zone II, 18 survived, and the success rate was 90 percent. Venous anastomosis was attempted in all cases, but it was possible in 39 zone I and in all zone II replantations. For arterial repair, vein grafts were necessary in 17 of the 44 zone I and in one of the 20 zone II replantations; for venous repair, they were necessary in six zone I replantations and one zone II replantation. Postoperative vascular complications occurred in 15 replantations. There were five cases of arterial thrombosis and 10 cases of venous congestion. Venous congestion occurred in nine zone I and one zone II replantations. In five of these 10 replantations, venous anastomosis was not possible. In another five replantations, venous outflow was established at the time of surgery, but occlusion occurred subsequently. Except for the five failures resulting from arterial thrombosis, successful venous repair was possible in 49 of 59 replantations (83 percent). Despite the demand for skillful microsurgical technique and longer operation time, the authors' results using venous anastomosis in successful fingertip replantations are encouraging. By performing venous anastomosis, external bleeding can be avoided and a higher survival rate can be achieved. Venous anastomosis for fingertip replantation is a reliable and worthwhile procedure.     

Staged reconstruction after gunshot wounds to the abdomen.

Immediate closure of abdominal incisions after exploration and treatment of gunshot wounds is not always feasible or advisable. Significant bowel edema after massive fluid resuscitation might preclude primary closure, whereas any attempt to close under tension might result in complications ranging from wound dehiscence, infection, and necrosis to the abdominal compartment syndrome with abdominal, cardiopulmonary, and renal complications. For these difficult cases, the open technique has been recommended. The abdomen is left open and is closed when the patient's condition permits. When immediate wound approximation is not possible, temporary coverage can be achieved with a mesh, patch, or a split-thickness skin graft and the definitive reconstruction is deferred for a more optimal time. The purpose of this retrospective study is to report the authors' experience with staged abdominal wall reconstruction after gunshot wounds. From 1989 to 1998, 1933 patients underwent exploratory laparotomy for penetrating wounds to the abdomen. Twenty-nine patients in grave condition and with multiple medical problems were comanaged by the Trauma and Plastic Surgery Services at Cook County Hospital with the following protocol: The abdomen was initially left open and exposed viscera were covered with a variety of methods, including a Gore-Tex patch (W. L. Gore and Associates, Inc., Flagstaff, Ariz.). A split-thickness graft was subsequently placed on the granulation tissue over viscera at an average of 14 days after the last laparotomy. These planned ventral hernias were definitively treated at an average of 7 months after the skin grafting procedure, primarily using the components separation technique. In 24 patients, the fascia was closed primarily without tension, while five patients required the use of synthetic mesh to restore fascial continuity. Nine patients underwent closure of a colostomy or repair of fistulas simultaneously with abdominal wall reconstruction. One patient developed a postoperative hernia, two developed superficial wound dehiscence that healed without further surgery, and one required re-exploration for a failed anastomosis after colostomy closure. All but one patient maintained a stable abdominal wall after the reconstruction. The authors concluded that staged abdominal wall reconstruction should be primarily recommended for patients with complex abdominal wounds and a compromised general condition that precludes primary closure. With this treatment protocol, patients can recover faster from their trauma surgery and the risk of perioperative complications can be reduced. After final reconstruction, the continuity, stability, and strength of the abdominal wall are maintained in the vast majority of cases with the use of autogenous tissue and without the need for alloplastic material. With close cooperation between the trauma team and the plastic surgeon and appropriate timing and planning of each stage, the success rate of the technique is high and the incidence of complications limited.     

The advantages of end-to-side arteriovenous anastomosis over the other two types of arteriovenous anastomosis in dialysis patients

The functional duration of vascular access in dialysis patients depends on the emergence of threatening complications. Discussions are constantly being held in an attempt to discover their causality and decrease their emergence. In 260 patients undergoing haemodialysis, we have studied the potential existence of a cause-and-effect relation between the emergence of complications in the vascular access and the applied type of arteriovenous (av.) anastomosis in the arteriovenous (AV) fistula. We have observed the incidence of all complications, both that of the thrombosis incidence as well as the primary and secondary fistula patency (survival). The complications--The examinees with the end-to-end anastomosis showed the incidence of 8.08%, 6.15% of the patients with the end-to-side anastomosis and 7.31% of the patients with the side-to-side anastomosis. The differences regarding incidences are statistically significant (chi2-test = 29.25; P = 0.0001). Thrombosis--it has been found that thrombosis was the most frequent complication developing in 30.00% patients with the end-to-end av. anastomosis, in 2.31% patients with end-to-side av. anastomosis and in 5.56% patients with side-to-side av. anastomosis. The difference between the highest and the lowest assessment is 27.69%, and it is statistically relevant (chi2-test = 33.920; P = 0.0001). The primary patency (primary survival): within a 6-month interval following the establishment of vascular access, the first complications arose in 62.50% of patients with end-to-end av. anastomosis, 10.76% in those with end-to-side av. anastomosis and 18.88% in those with side-to-side av. anastomosis. The difference between the highest and the lowest assessment is 51.74%, which is statistically significant (chi2-test = 49.009; P = 0.0001). The secondary patency: 24 months subsequent to the establishment of vascular access, the AV-fistula was still functional in 52.50% of the patients with end-to-end av. anastomosis, 89.23% in those with end-to-side av. anastomosis and 81.11% in those with side-to-side av. anastomosis. The difference between the highest and the lowest assessment is 36.73%, which is also statistically significant (chi2-test = 26.579; P = 0.0001). According to our research, the end--to-side type of av. anastomosis in vascular access provides better results both in relation to the duration as well as the maintenance of the functionality of the Av-fistula and in the lower incidence of the complications than the other types, and hence it shows a definite advantage.     

Large-scale validation of a latex agglutination test for diagnosis of tuberculosis

Large-scale validation of a simple latex agglutination test for the diagnosis of tuberculosis is described. Soluble antigens extracted from a non-pathogenic saprophytic mycobacterium, Mycobacterium w, which shares antigenic determinants with Mycobacterium tuberculosis, were covalently linked to carboxylated polystyrene latex beads. Batch to batch reproducibility of coated latex was ensured. Latex reagents were standardized to overcome non-specific agglutination. Reagents of the test are stable for 1 year at 4 degrees C. A total of 1,058 serum samples of pulmonary and extrapulmonary tuberculosis patients or patients with other pulmonary diseases and healthy controls living in endemic areas were tested. Sensitivity of 94% for pulmonary tuberculosis and 87% for extrapulmonary tuberculosis was obtained. Specificity is 92.2% for healthy controls and patients with other respiratory diseases. We conclude that the latex agglutination test can be utilized for mass screening for both pulmonary and extrapulmonary tuberculosis where diagnosis by existing methods is much more difficult.